382 - Obesity Pandemic, Obesity Management, Weight Loss in Underserved
Take 3 – Practical Practice Pointers©
From the CDC’s National Center for Healthcare Statistics (NCHS)
1) Obesity is the “Other” Pandemic – and it Started in the US
It is recognized that obesity is caused by a complex relationship between genetic, socioeconomic, and cultural influences, and that individual and communal lifestyle habits influence its prevalence. The CDC defines people with a BMI below 18.5 as being underweight, 18.5 – 24.9 as normal or healthy weight, 25 – 29.9 as overweight, 30 – 39.9 as obese and > 40 as severe obesity.
According to recently published data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES), the prevalence of obesity in American children, adolescents, and adults is the highest it has ever been. Among American adults, 9% had severe obesity, 42% had obesity, and another 31% overweight. Men age 40-59 had the highest rate of obesity at 46%. By comparison, in national data from the survey period of 1960-1962, only 13% of adults had obesity and 32% were considered overweight with less than 1% having severe obesity.
Here is what that looks like in graphic form over the past 60 years.
For children and adolescents, BMI is age- and sex-specific. For children and adolescents of the same age and sex, a BMI at or above the 85th percentile and below the 95th percentile signals overweight, a BMI > 95th percentile indicates obesity, and a BMI > 120% of the 95th percentile is defined as severe obesity. According to the 2017-2018 NHANES data on children and adolescents, 19% ages 2-19 had obesity, 6% were identified as having severe obesity, and another 16% were overweight. Obesity rates followed a similar trajectory as adults over the past several decades.
The graphic speaks for itself. STUNNING! Sadly, as a society (and perhaps as a profession) we’ve almost become numb to these statistics, and our collective “learned helplessness” has created circumstances where being obese is literally the “new normal.” Perhaps our present COVID pandemic and the apparent increased morbidity and mortality among those who are obese will serve as a wake-up call that the health consequences of this “other pandemic” are quite real. Read on for more.
- Fayer C et al. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. NCHS Health E-Stats. 11 December 2020. Link
- Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018. NCHS Health E-Stats. 2020. Link
From the Guidelines
2) The Obesity Pandemic – What Can be Done?
There is increasing recognition that obesity management should be about improved health and well-being, and not just weight loss. Despite growing evidence that obesity is a serious chronic disease, it is not effectively managed within our current health system. Most clinicians feel ill equipped to support people living with obesity. Biased beliefs about obesity also affect the level and quality of health care that patients receive. The dominant cultural narrative fuels assumptions about personal irresponsibility and lack of willpower and often casts blame and shame upon people with obesity. Importantly, obesity stigma negatively influences the level and quality of care.
A recently published Canadian guideline provides an update of the evidence regarding obesity management as well as a roadmap for a paradigm shift. The guideline describes an “arc” of the patient clinical management journey. There are 5 steps in the process to guide clinicians. These include:
- Recognition of obesity as a chronic progressive and relapsing disease, and engaging patients in a dialogue in a non-judgmental and unbiased manner.
- Performing a comprehensive assessment using appropriate measurements, and identifying the root causes, complications and barriers to obesity treatment.
- Having an evidence-informed discussion of the core treatment options (medical nutrition therapy and physical activity) and adjunctive therapies that may be required, including psychological, pharmacologic and surgical interventions.
- Establishing mutually agreed upon goals of therapy, focusing mainly on the value that patients might derive from health-based interventions.
- Engaging with patients in continued follow-up and reassessments.
The guideline emphasizes that obesity care should be based on evidence-based principles of chronic disease management, validate patients’ lived experiences, move beyond simplistic approaches of “eat less, move more,” and address the root drivers of obesity.
There is much more to this guideline, including numerous specific recommendations with levels of evidence. There were a few items that I found particularly notable:
- The focus on health and well-being (improvement of risk factors and mental health) rather than simply focusing on a "target weight".
- Importance of recognition of our biases toward obesity. For those who would claim they don’t have such biases, consider taking the “Implicit Bias Test for Weight” (see references). It might be eye-opening for you.
- The more liberal use of medications as part of a comprehensive treatment plan. I recognize my own biases when it comes to these.
- Some highlights from their Level 1a, Grade A recommendations of note:
- The use of metformin as a preventative for patients on long term antipsychotics
- The use of Weight Watchers (WW), which is a well-structured and relatively cost-effective resource
Additionally, I reached out to Lauren Self, DO and David Salzberg, MD, who serve as the Medical Directors for the Carilion Bariatric Medicine and Bariatric Surgery programs respectively. They responded: “The Canadian guideline is straightforward and helpful. Despite our best efforts, the rates of obesity continue to rise, and it almost appears we are fighting a losing battle. But it is not. We encourage you to begin new conversations with your patients this year. Have simple, clear recommendations about food. The world of nutrition can be confusing so to keep it simple. We use the Canadian Food Guide (Link) as it is visually engaging and simple. It keeps water on the side of the plate, eliminates fried foods, and prioritizes high fiber intake. Second, recommend a significant reduction in ultra-processed foods. The classification of food processing can be found here: Link . Ultra-processed foods are highly palatable and can lead to greatly increased caloric intake and weight gain.
Anti-obesity medications are significantly under prescribed with just under half of the US population qualifying for treatment and only 2% receiving therapy. Additionally, recent studies have confirmed long term benefits of bariatric surgery with remission of co-morbidities including 46% of hypertension and 58% of diabetes after 10 years. Mean percentage of excess weight loss remained close to 60%.”
They also recommend consideration of a bariatric specialty referral for all patients with a BMI > 40 or > 35 with comorbidities, particularly those who have not responded to your care.
The challenge is quite great, and following the model for tobacco cessation, addressing obesity will require the long view and cultural as well as individual interventions. Unfortunately, the just released US Government Dietary Guidelines (3rd Reference) are not a particularly helpful or urgent response to our “Obesity pandemic.”
From the Literature
3) Achieving Weight Loss in Underserved Populations
The reliance on primary care clinicians to deliver obesity treatment has limitations, in part because of the limited time available during office visits, a lack of training in intensive behavioral therapy, and low reimbursement. A recently published cluster-randomized trial tested the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. The authors randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention provided by embedded health coaches, or usual care. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months.
At 24 months, 51% of the intervention group had at least 5% weight loss compared with 20% of the patients in the usual-care group. Additionally, 23% of the intervention group had at least 10% weight loss compared with 5% in the control group. The average weight loss in the intervention group was 10 pounds vs. 2 in the control group. The authors concluded that a high-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population resulted in clinically significant weight loss at 24 months.
While this may not seem very impressive considering the extensive resources utilized, this gives us a sense of the challenges that lie ahead if we as a society are to get serious about addressing obesity. The cost of not doing so is very much greater.
- Katzmarzyk P et al. Weight Loss in Underserved Patients: A Cluster-Randomized Trial. N Engl J Med. Sept 3, 2020; 383:909-918. Abstract
Mark and John
Carilion Clinic Department of Family and Community Medicine
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